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Kalata S, Thumma JR, Sheetz KH. Common Bile Duct Injury in Cholecystectomy-Reply. JAMA Surg 2024; 159:592. [PMID: 38416476 DOI: 10.1001/jamasurg.2023.8084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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2
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Baxter NB, Pediyakkal HF, DeShazor-Burnett LJ, Speyer CB, Richburg CE, Howard RA, Rob F, Thumma JR, Telem DA, Ehlers AP. Outcomes of Emergency Parastomal Hernia Repair in Older Adults: A Retrospective Analysis. J Surg Res 2024; 293:596-606. [PMID: 37837814 DOI: 10.1016/j.jss.2023.09.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/15/2023] [Accepted: 09/06/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Parastomal hernias are common and many are never repaired. Emergency parastomal hernia repair (PHR) is a feared complication following ostomy creation, yet the incidence and long-term outcomes of emergency PHR are unknown. MATERIALS AND METHODS We performed a retrospective analysis of 100% Medicare claims data (2007-2015) to evaluate complications, readmissions, reoperations, hospitalizations, and mortality after emergency PHR. We used logistic regression and Cox proportional hazard models to determine the association of surgical approach, including repair with ostomy reversal, resiting, mesh, minimally invasive approach, or a myofascial flap. Analysis took place between June 2022 and February 2023. RESULTS A total of 6658 patients underwent emergency PHR (mean [standard deviation] age, 75.9 [9.8] y; 4031 female individuals [60.5%]). Overall, 3433 (51.2%) patients underwent primary PHR, 1626 (24.4%) underwent PHR with ostomy resiting, and 1599 (24.0%) underwent PHR with ostomy reversal. In the 30 d after surgery, 4151 (62.3%) patients had complications and 55 (0.83%) underwent reoperation. Compared to local repair, the 30-d odds of complications were lower for patients who underwent ostomy resiting (odds ratio 0.82 [95% confidence interval 0.72-0.93]). Five y after surgery, the cumulative incidence of reoperation was 12.0% and was lowest for patients who underwent PHR with ostomy reversal (hazard ratio 0.15 [95% confidence interval 0.11-0.21]) when compared to local repair. CONCLUSIONS Emergency PHR is associated with significant morbidity. However, technique selection may influence outcomes. Understanding the prognosis of emergency PHR may improve decision-making and patient counseling for patients living with this common disease.
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Affiliation(s)
| | | | | | | | | | - Ryan A Howard
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Farizah Rob
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Dana A Telem
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Anne P Ehlers
- Department of General Surgery, Michigan Medicine, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
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Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg 2023; 158:1303-1310. [PMID: 37728932 PMCID: PMC10512167 DOI: 10.1001/jamasurg.2023.4389] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/10/2023] [Indexed: 09/22/2023]
Abstract
Importance Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear. Objective To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy. Design, Setting, and Participants This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023. Exposure Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches. Main Outcomes and Measures The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups. Results A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]). Conclusions and Relevance This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Edward C. Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor
- Department of Economics, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Section Editor, JAMA Surgery
| | - Kyle H. Sheetz
- Department of Surgery, University of California, San Francisco
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4
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Bonner SN, Thumma JR, Valbuena VSM, Stewart JW, Combs M, Lyu D, Chang A, Lin J, Wakeam E. The intersection of race and ethnicity, gender, and primary diagnosis on lung transplantation outcomes. J Heart Lung Transplant 2023; 42:985-992. [PMID: 36967318 DOI: 10.1016/j.healun.2023.02.1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 01/10/2023] [Accepted: 02/18/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Reducing racial disparities in lung transplant outcomes is a current priority of providers, policymakers, and lung transplant centers. It is unknown how the combined effect of race and ethnicity, gender, and diagnosis group is associated with differences in 1-year mortality and 5-year survival. METHODS This is a longitudinal cohort study using Standard Transplant Analysis Research files from the United Network for organ sharing. A total of 25,444 patients undergoing first time lung transplantation between 2006 and 2019 in the United States. The primary exposures were lung transplant recipient race and ethnicity, gender, and primary diagnosis group at listing. Multivariable regression models and cox-proportional hazards models were used to determine adjusted 1-year mortality and 5-year survival. RESULTS Overall, 25,444 lung transplant patients were included in the cohort including 15,160 (59.6%) men, 21,345 (83.9%) White, 2,318 (9.1%), Black and Hispanic/Latino (7.0%). Overall, men had a significant higher 1-year mortality than women (11.87%; 95% CI 11.07-12.67 vs 12.82%; 95% CI 12.20%-13.44%). Black women had the highest mortality of all race and gender combinations (14.51%; 95% CI 12.15%-16.87%). Black patients with pulmonary vascular disease had the highest 1-year mortality (19.77%; 95% CI 12.46%-27.08%) while Hispanic/Latino patients with obstructive lung disease had the lowest (7.42%; 95% CI 2.8%-12.05%). 5-year adjusted survival was highest among Hispanic/Latino patients (62.32%) compared to Black (57.59%) and White patients (57.82%). CONCLUSIONS There are significant differences in 1-year and 5-year mortality between and within racial and ethnic groups depending on gender and primary diagnosis. This demonstrates the impact of social and clinical factors on lung transplant outcomes.
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Affiliation(s)
- Sidra N Bonner
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan.
| | - Jyothi R Thumma
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Valeria S M Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - James W Stewart
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Yale University, New Haven, Connecticut
| | - Michael Combs
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Dennis Lyu
- Department of Internal Medicine, Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Andrew Chang
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Elliot Wakeam
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
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Bonner SN, Thumma JR, Dimick JB, Sheetz KH. Trends in Use of Robotic Surgery for Privately Insured Patients and Medicare Fee-for-Service Beneficiaries. JAMA Netw Open 2023; 6:e2315052. [PMID: 37223903 PMCID: PMC10209745 DOI: 10.1001/jamanetworkopen.2023.15052] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/11/2023] [Indexed: 05/25/2023] Open
Abstract
This cohort study evaluates trends in the adoption of robotic surgery among Medicare beneficiaries and privately insured patients for common general surgical procedures.
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Affiliation(s)
- Sidra N. Bonner
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
- National Clinician Scholars Program, University of Michigan, Ann Arbor
| | - Jyothi R. Thumma
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
| | - Kyle H. Sheetz
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco
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6
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Chao GF, Yang J, Peahl A, Thumma JR, Dimick JB, Arterburn DE, Telem DA. Births After Bariatric Surgery in the United States: Incidence, Obstetric Outcomes, and Reinterventions. Ann Surg 2023; 277:e801-e807. [PMID: 35762610 PMCID: PMC9794635 DOI: 10.1097/sla.0000000000005438] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To characterize incidence and outcomes for bariatric surgery patients who give birth. BACKGROUND Patients of childbearing age comprise 65% of bariatric surgery patients in the United States, yet data on how often patients conceive and obstetric outcomes are limited. METHODS Using the IBM MarketScan database, we performed a retrospective cohort study of female patients ages 18 to 52 undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011 to 2017. We determined the incidence of births in the first 2 years after bariatric surgery using Kaplan-Meier estimates. We then restricted the cohort to those with a full 2-year follow-up to examine obstetric outcomes and bariatric-related reinterventions. We reported event rates of adverse obstetric outcomes and delivery type. Adverse obstetric outcomes include pregnancy complications, severe maternal morbidity, and delivery complications. We performed multivariable logistic regression to examine associations between birth and risk of reinterventions. RESULTS Of 69,503 patients who underwent bariatric surgery, 1464 gave birth. The incidence rate was 2.5 births per 100 patients in the 2 years after surgery. Overall, 85% of births occurred within 21 months after surgery. For 38,922 patients with full 2-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. In all, 48.5% were first-time cesarean deliveries. Almost all reinterventions during pregnancy were biliary. Multivariable logistic regression analysis showed no association between postbariatric birth and reintervention rate (odds ratio: 0.93, 95% confidence interval: 0.78-1.12). CONCLUSIONS In this first national US cohort, we find giving birth was common in the first 2 years after bariatric surgery and was not associated with an increased risk of reinterventions. Clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decision-making with maternal safety as one component.
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Affiliation(s)
- Grace F. Chao
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Veterans Affairs Ann Arbor, Ann Arbor, MI
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Alex Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - David E. Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Dana A. Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
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Chao GF, Yang J, Thumma JR, Chhabra KR, Arterburn DE, Ryan AM, Telem DA, Dimick JB. Out-of-pocket Costs for Commercially-insured Patients in the Years Following Bariatric Surgery: Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass. Ann Surg 2023; 277:e332-e338. [PMID: 35129487 PMCID: PMC9091055 DOI: 10.1097/sla.0000000000005291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare out-of-pocket (OOP) costs for patients up to 3 years after bariatric surgery in a large, commercially-insured population. SUMMARY OF BACKGROUND DATA More information on OOP costs following bariatric surgery may affect patients' procedure choice. METHODS Retrospective study using the IBM MarketScan commercial claims database, representing patients nationally who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) January 1, 2011 to December 31, 2017. We compared total OOP costs after the surgical episode between the 2 procedures using difference-in-differences analysis adjusting for demographics, comorbidities, operative year, and insurance type. RESULTS Of 63,674 patients, 64% underwent SG and 36% underwent RYGB. Adjusted OOP costs after SG were $1083, $1236, and $1266 postoperative years 1, 2, and 3. For RYGB, adjusted OOP costs were $1228, $1377, and $1369. In our primary analysis, SG OOP costs were $122 (95% confidence interval [CI]: -$155 to -$90) less than RYGB year 1. This difference remained consistent at -$119 (95%CI: -$158 to -$79) year 2 and -$80 (95%CI: -$127 to -$35) year 3. These amounts were equivalent to relative differences of -7%, -7%, and -5% years 1, 2, and 3. Plan features contributing the most to differences were co-insurance years 1, 2, and 3.The largest clinical contributors to differences were endoscopy and outpatient care year 1, outpatient care year 2, and emergency department use year 3. CONCLUSIONS Our study is the first to examine the association between bariatric surgery procedure and OOP costs. Differences between procedures were approximately $100 per year which may be an important factor for some patients deciding whether to pursue SG or gastric bypass.
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Affiliation(s)
- Grace F. Chao
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Veterans Affairs Ann Arbor, Ann Arbor, MI
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Karan R. Chhabra
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - David E. Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Andrew M. Ryan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor, MI
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Dana A. Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
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8
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Chao GF, Yang J, Peahl AF, Thumma JR, Dimick JB, Arterburn DE, Telem DA. Comparative effectiveness of sleeve gastrectomy vs Roux-en-Y gastric bypass in patients giving birth after bariatric surgery: reinterventions and obstetric outcomes. Surg Endosc 2022; 36:6954-6968. [PMID: 35099628 DOI: 10.1007/s00464-022-09063-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Women of childbearing age comprise approximately 65% of all patients who undergo bariatric surgery in the USA. Despite this, data on maternal reintervention and obstetric outcomes after surgery are limited especially with regard to comparative effectiveness between sleeve gastrectomy and Roux-en-Y gastric bypass, the most common procedures today. METHODS Using IBM MarketScan claims data, we performed a retrospective cohort study of women ages 18-52 who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass with 2-year continuous follow-up. We balanced the cohort on observable characteristics using inverse probability weighting. We utilized multivariable logistic regression to examine the association between procedure selection and outcomes, including risk of reinterventions (revisions, enteral access, vascular access, reoperations, other) or adverse obstetric outcomes (pregnancy complications, severe maternal morbidity, and delivery complications). In all analyses, we controlled for age, U.S. state, and Elixhauser or Bateman comorbidities. RESULTS From 2011 to 2016, 1,079 women gave birth within the first two years after undergoing bariatric surgery. Among these women, we found no significant difference in reintervention rates among those who had gastric bypass compared to sleeve gastrectomy (OR 1.41, 95% CI 0.91-2.21, P = 0.13). We then examined obstetric outcomes in the patients who gave birth after bariatric surgery. Compared to patients who underwent sleeve gastrectomy, those who had Roux-en-Y gastric bypass were not significantly more likely to experience any adverse obstetric outcomes. CONCLUSION In this first national cohort of females giving birth following bariatric surgery, no significant difference was observed in persons who underwent Roux-en-Y gastric bypass versus sleeve gastrectomy with respect to either reinterventions or obstetric outcomes. This suggests possible equipoise between these two procedures with regards to safety within the first two years following a bariatric procedure among women who may become pregnant, but more research is needed to confirm these findings in larger samples.
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Affiliation(s)
- Grace F Chao
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Veterans Affairs Ann Arbor, Ann Arbor, MI, USA.
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Alex F Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Dana A Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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9
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Solano QP, Thumma JR, Mullens C, Howard R, Ehlers A, Delaney L, Fry B, Shen M, Englesbe M, Dimick J, Telem D. Variation of ventral and incisional hernia repairs in kidney transplant recipients. Surg Endosc 2022; 37:3173-3179. [PMID: 35962230 DOI: 10.1007/s00464-022-09505-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/23/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION As survivorship following kidney transplant continues to improve, so does the probability of intervening on common surgical conditions, such as ventral or incisional hernia, in this population. Ventral hernia management is known to vary across institutions and this variation has an impact on patient outcomes. We sought to evaluate hospital level variation of ventral or incisional hernia repair (VIHR) in the kidney transplant population. METHODS We performed a retrospective review of 100% inpatient Medicare claims to identify patients who underwent kidney transplant between 2007 and 2018. The primary outcome was 1- and 3-year ventral or incisional risk- and reliability-adjusted VIHR rates. Patient and hospital characteristics were evaluated across risk- and reliability-adjusted VIHR rate tertiles. Models were adjusted for age, sex, race, and Elixhauser comorbidities. RESULTS Overall, 139,741 patients underwent kidney transplant during the study period with a mean age (SD) of 51.6 (13.7) years. 84,717 (60.6%) were male, and 72,657 (52.0%) were white. Median follow up time was 5.4 years. 2098 (1.50%) patients underwent VIHR. the 1 year risk- and reliability-adjusted hernia repair rates were 0.49% (95% Conf idence Interval (CI) 0.48-0.51, range 0.31-0.59) in tertile 1, 0.63% (95% CI 0.62-0.63, range 0.59-0.68) in tertile 2, and 0.98 (95% CI 0.91-1.05, range 0.68-2.94) in tertile 3. Accordingly, compared to hospitals in tertile 1, the odds of post-transplant hernia repair tertile 2 hospitals were 1.78 (95% CI 1.37-2.31) and at tertile 3 hospitals 3.53 (95% CI 2.87-4.33). CONCLUSIONS In a large cohort of Medicare patients undergoing kidney transplant, the overall cumulative incidence of hernia repair varied substantially across hospital tertiles. Patient and hospital characteristics varied across tertile, most notably in diabetes and obesity. Future research is needed to understand if program and surgeon level factors are contributing to the observed variation in treatment of this common disease.
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Affiliation(s)
- Quintin P Solano
- University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Cody Mullens
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Howard
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne Ehlers
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lia Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian Fry
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mary Shen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA
| | - Dana Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. .,Department of Surgery, University of Michigan, Ann Arbor, MI, USA. .,Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA.
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10
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Wakeam E, Thumma JR, Bonner SN, Chang AC, Reddy RM, Lagisetty K, Lynch W, Grenda T, Chan K, Lyu D, Lin J. One-year Mortality Is Not a Reliable Indicator of Lung Transplant Center Performance. Ann Thorac Surg 2022; 114:225-232. [PMID: 35247344 DOI: 10.1016/j.athoracsur.2022.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/25/2022] [Accepted: 02/09/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND In the United States, the Organ Procurement and Transplant Network uses one-year mortality as the primary measure of transplant center quality. We sought to evaluate the reliability of mortality outcomes in lung transplant and compare statistical methods of program performance evaluation. METHODS We used the Standard Transplant Analysis and Research files from the United Network for Organ Sharing to identify lung transplant recipients from 2013-2018 in the United States. We stratified hospitals based on 30-day, 1-year and 5-year survival using risk adjustment, reliability adjustment using empirical Bayes technique, and hierarchical Bayesian mixed-effects models currently used by the OPTN. We measured variation in mortality rates and identification of performance outliers between techniques. RESULTS We identified 12,769 recipients in 69 centers. Reliability adjustment reduced variation in hospital outcomes and had a large impact on hospital mortality rankings. For example, with 1-year mortality, 28% (5 hospitals) of the "best" hospitals (top 25%) and 18% (3 hospitals) of the "worst" hospitals (bottom 25%) were reclassified after reliability adjustment. The overall reliability of 1-year mortality was low at 0.42. Compared to the Bayesian method used by the OPTN, reliability adjustment identified fewer outliers. 5-year survival reached a higher reliability plateau with a lower volume of cases required. CONCLUSIONS The reliability of 1-year mortality in lung transplantation is low, while 5-year survival estimates may be more reliable at lower case volumes. Reliability adjustment yielded more conservative measures of center performance and fewer outliers compared to current Bayesian methods.
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Affiliation(s)
- Elliot Wakeam
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI.
| | - Jyothi R Thumma
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Sidra N Bonner
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI; Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Andrew C Chang
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Rishindra M Reddy
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kiran Lagisetty
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - William Lynch
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Tyler Grenda
- Division of Thoracic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Kevin Chan
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Dennis Lyu
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Jules Lin
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
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11
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Howard R, Chao GF, Yang J, Thumma JR, Arterburn DE, Telem DA, Dimick JB. Medication Use for Obesity-Related Comorbidities After Sleeve Gastrectomy or Gastric Bypass. JAMA Surg 2022; 157:248-256. [PMID: 35019988 PMCID: PMC8756362 DOI: 10.1001/jamasurg.2021.6898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear. OBJECTIVE To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021. EXPOSURES Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOMES AND MEASURES The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation. RESULTS Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]). CONCLUSIONS AND RELEVANCE Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Grace F. Chao
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor,Veterans Affairs Ann Arbor, Ann Arbor, Michigan,Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | | | - Dana A. Telem
- Department of Surgery, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor,Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor
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12
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Chhabra KR, Ghaferi AA, Yang J, Thumma JR, Dimick JB, Tsai TC. Relationship Between Health Care Spending and Clinical Outcomes in Bariatric Surgery: Implications for Medicare Bundled Payments. Ann Surg 2022; 275:356-362. [PMID: 33055585 DOI: 10.1097/sla.0000000000003979] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care. SUMMARY OF BACKGROUND DATA Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement. METHODS Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models. RESULTS Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001). CONCLUSIONS AND RELEVANCE In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.
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Affiliation(s)
- Karan R Chhabra
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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13
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Greenberg CC, Byrnes ME, Engler TA, Thumma JR, Dimick JB, Quamme SP. Response to the Comment on "Greenberg et al 2021 Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions". Ann Surg 2021; 274:e928-e929. [PMID: 34353990 PMCID: PMC8599632 DOI: 10.1097/sla.0000000000005135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Caprice C Greenberg
- Department of Surgery, Medical College of Georgia at Augusta University, Augusta, GA
| | - Mary E Byrnes
- Center for Healthcare Outcomes and Policy (CHOP), Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Tedi A Engler
- Center for Healthcare Outcomes and Policy (CHOP), Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy (CHOP), Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy (CHOP), Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Sudha Pavuluri Quamme
- Wisconsin Surgical Outcomes Research Program (WiSOR), Department of Surgery, University of Wisconsin, Madison, WI
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15
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Greenberg CC, Byrnes ME, Engler TA, Quamme SP, Thumma JR, Dimick JB. Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions. Ann Surg 2021; 273:1034-1039. [PMID: 33605579 PMCID: PMC8119316 DOI: 10.1097/sla.0000000000004800] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons. SUMMARY OF BACKGROUND DATA Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes. METHODS This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program. RESULTS The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62-1.37), 0.91 (0.64-1.17), and 1.15 (0.83-1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of -14.0 (-22.3, -5.7), -1.0 (-4.5, 2.4), and -2.6 (-6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review. CONCLUSIONS This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.
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Affiliation(s)
- Caprice C. Greenberg
- Department of Surgery, University of Wisconsin, and the Wisconsin Surgical Outcomes Research Program (WiSOR), Madison, WI
| | - Mary E. Byrnes
- Department of Surgery, University of Michigan and the Center for Healthcare Outcomes and Policy (CHOP), Ann Arbor, MI
| | - Tedi A. Engler
- Department of Surgery, University of Michigan and the Center for Healthcare Outcomes and Policy (CHOP), Ann Arbor, MI
| | - Sudha Pavuluri Quamme
- Department of Surgery, University of Wisconsin, and the Wisconsin Surgical Outcomes Research Program (WiSOR), Madison, WI
| | - Jyothi R Thumma
- Department of Surgery, University of Michigan and the Center for Healthcare Outcomes and Policy (CHOP), Ann Arbor, MI
| | - Justin B. Dimick
- Department of Surgery, University of Michigan and the Center for Healthcare Outcomes and Policy (CHOP), Ann Arbor, MI
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16
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Chhabra KR, Thumma JR, Varban OA, Dimick JB. Associations Between Video Evaluations of Surgical Technique and Outcomes of Laparoscopic Sleeve Gastrectomy. JAMA Surg 2021; 156:e205532. [PMID: 33325998 DOI: 10.1001/jamasurg.2020.5532] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes. Objective To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy. Design, Setting, and Participants In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016. Exposures Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing. Main Outcomes and Measures The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument). Results A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P < .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47). Conclusions and Relevance Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.
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Affiliation(s)
- Karan R Chhabra
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Oliver A Varban
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor.,Section Editor, JAMA Surgery
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Abstract
The Hospital Readmissions Reduction Program, announced in 2010 to penalize excess readmissions for patients with selected medical diagnoses, was expanded in 2013 to include targeted surgical diagnoses, beginning with hip and knee replacements. Whether these surgical penalties reduced procedure-specific readmissions is not well understood. Using Medicare claims, we evaluated the penalty announcements' effects on risk-adjusted readmission rates, episode payments, lengths-of-stay, and observation status use. Risk-adjusted readmission rates declined for both procedures from 7.6 percent in 2008 to 5.5 percent in 2016. These rates were decreasing before the program was announced, but the rate of reductions doubled after the announcement of medical penalties in March 2010 (from -0.05 percentage points to -0.10 percentage points per quarter). After targeted surgical penalties were announced in August 2013, readmission reductions returned to near the baseline trend. During the same time period, mean episode payments and lengths-of-stay decreased substantially, and trends in observation status were unchanged. This suggests that medical readmission penalties led to readmission reductions for surgical patients as well, that targeted surgical penalties did not have an additional effect, and that readmission reductions are approaching a "floor" below which further reductions may be unlikely.
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Affiliation(s)
- Karan R Chhabra
- Karan R. Chhabra ( ) is a National Clinician Scholar at the Institute for Healthcare Policy and Innovation and a fellow at the Center for Healthcare Outcomes and Policy, both at the University of Michigan, in Ann Arbor, and a house officer in the Department of Surgery at Brigham and Women's Hospital, in Boston, Massachusetts
| | - Andrew M Ibrahim
- Andrew M. Ibrahim is a house officer in the Department of Surgery, University of Michigan, and chief medical officer of HOK, a global architecture and design firm, in Chicago, Illinois
| | - Jyothi R Thumma
- Jyothi R. Thumma is a statistician at the Center for Healthcare Outcomes and Policy, University of Michigan
| | - Andrew M Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management in the Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
| | - Justin B Dimick
- Justin B. Dimick is the Frederick A. Coller Professor and Chair of the Department of Surgery, University of Michigan
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18
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Varban OA, Thumma JR, Carlin AM, Finks JF, Ghaferi AA, Dimick JB. Peer Assessment of Operative Videos with Sleeve Gastrectomy to Determine Optimal Operative Technique. J Am Coll Surg 2020; 231:470-477. [DOI: 10.1016/j.jamcollsurg.2020.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
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19
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Ehlers AP, Chhabra K, Thumma JR, Dimick JB, Varban O. In the eye of the beholder: surgeon variation in intra-operative perceptions of hiatal hernia and reflux outcomes after sleeve gastrectomy. Surg Endosc 2020; 35:2537-2542. [DOI: 10.1007/s00464-020-07668-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022]
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20
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Varban OA, Thumma JR, Telem DA, Obeid NR, Finks JF, Ghaferi AA, Dimick JB. Goldilocks Principle: Video Assessment of a Sleeve Gastrectomy That is “Just Right”. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
OBJECTIVE To evaluate whether hospital participation in accountable care organizations (ACOs) is associated with reduced Medicare spending for inpatient surgery. BACKGROUND ACOs have proliferated rapidly and now cover more than 32 million Americans. Medicare Shared Savings Program (MSSP) ACOs have shown modest success in reducing medical spending. Whether they have reduced surgical spending remains unknown. METHODS We used 100% Medicare claims from 2010 to 2014 for patients aged 65 to 99 years undergoing 6 common elective surgical procedures [abdominal aortic aneurysm (AAA) repair, colectomy, coronary artery bypass grafting (CABG), hip or knee replacement, or lung resection]. We compared total Medicare payments for 30-day surgical episodes, payments for individual components of care (index hospitalization, readmissions, physician services, and postacute care), and clinical outcomes for patients treated at MSSP ACO hospitals versus matched controls at non-ACO hospitals. We accounted for preexisting trends independent of ACO participation using a difference-in-differences approach. RESULTS Among 341,675 patients at 427 ACO hospitals and 1,024,090 matched controls at 1531 non-ACO hospitals, patient and hospital characteristics were well-balanced. Average baseline payments were similar at ACO versus non-ACO hospitals. ACO participation was not associated with reductions in total Medicare payments [difference-in-differences estimate=-$72, confidence interval (CI95%): -$228 to +$84] or individual components of payments. ACO participation was also not associated with clinical outcomes. Duration of ACO participation did not affect our estimates. CONCLUSION Although Medicare ACOs have had success reducing spending for medical care, they have not had similar success with surgical spending. Given that surgical care accounts for 30% of total health care costs, ACOs and policymakers must pay greater attention to reducing surgical expenditures.
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Affiliation(s)
- Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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Varban OA, Thumma JR, Finks JF, Carlin AM, Ghaferi AA, Dimick JB. Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-Based Study. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Varban OA, Thumma JR, Finks JF, Carlin AM, Kemmeter PR, Ghaferi AA, Dimick JB. Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study. Surg Endosc 2018; 33:895-903. [DOI: 10.1007/s00464-018-6382-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
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25
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Shubeck SP, Thumma JR, Dimick JB, Nathan H. Hospital quality, patient risk, and Medicare expenditures for cancer surgery. Cancer 2017; 124:826-832. [DOI: 10.1002/cncr.31120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/12/2017] [Accepted: 10/16/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Sarah P. Shubeck
- National Clinician Scholars Program at the Institute for Healthcare Policy & Innovation; University of Michigan; Ann Arbor Michigan
- Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Jyothi R. Thumma
- Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Justin B. Dimick
- Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Hari Nathan
- Department of Surgery; University of Michigan; Ann Arbor Michigan
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Abstract
Importance Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known. Objective To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort. Design, Settings, and Participants This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band-related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed. Main Outcomes and Measures Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations. Results Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P < .001) and diabetes (40.4% vs 44.6%; P < .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P < .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid $470 million for laparoscopic gastric band associated procedures, of which $224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device. Conclusions and Relevance Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.
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Affiliation(s)
- Andrew M Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Surgical Innovation Editor
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Abstract
Importance In the United States, reports about perioperative complications associated with bariatric surgery led to the establishment of accreditation criteria for bariatric centers of excellence and many bariatric centers obtaining accreditation. Currently, most bariatric procedures occur at these centers, but to what extent they uniformly provide high-quality care remains unknown. Objective To describe the variation in surgical outcomes across bariatric centers of excellence and the geographic availability of high-quality centers. Design, Setting, and Participants This retrospective review analyzed the claims data of 145 527 patients who underwent bariatric surgery at bariatric centers of excellence between January 1, 2010, and December 31, 2013. Data were obtained from the Healthcare Cost and Utilization Project's State Inpatient Database. This database included unique hospital identification numbers in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin), allowing comparisons among 165 centers of excellence located in those states. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those included in the study cohort were patients with a primary diagnosis of morbid obesity and who underwent laparoscopic Roux-en-Y gastric bypass, open Roux-en-Y gastric bypass, laparoscopic gastric band placement, or laparoscopic sleeve gastrectomy. Excluded from the cohort were patients younger than 18 years or who had an abdominal malignant neoplasm. Data were analyzed July 1, 2016, through January 10, 2017. Main Outcomes and Measures Risk-adjusted and reliability-adjusted serious complication rates within 30 days of the index operation were calculated for each center. Centers were stratified by geographic location and operative volume. Results In this analysis of claims data from 145 527 patients, wide variation in quality was found across 165 bariatric centers of excellence, both nationwide and statewide. At the national level, the risk-adjusted and reliability-adjusted serious complication rates at each center varied 17-fold, ranging from 0.6% to 10.3%. At the state level, variation ranged from 2.1-fold (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold (Nebraska decile range, 1.0%-10.3%). After dividing hospitals into quintiles of quality on the basis of their adjusted complication rates, 38 of 132 (28.8%) had a center in a higher quintile of quality located within the same hospital service area. Variation in rates of complications existed at centers with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation). Conclusions and Relevance Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.
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Affiliation(s)
- Andrew M Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor2Surgical Innovation Editor, JAMA Surgery
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Abstract
OBJECTIVE To examine the relationship between hospital outcomes and expenditures in patients undergoing bariatric surgery in the United States. BACKGROUND As one of the most common surgical procedures in the United States, bariatric surgery is a major focus of policy reforms aimed at reducing surgical costs. These policy mechanisms have made it imperative to understand the potential cost savings of quality-improvement initiatives. METHODS We performed a retrospective review of 38,374 Medicare beneficiaries undergoing bariatric surgery between 2011 and 2013. We ranked hospitals into quintiles by their risk and reliability-adjusted postoperative serious complications. We then examined the relationship between upper and lower outcome quintiles with risk-adjusted total episode payments. Additionally, we stratified patients by their risk (low, medium, high) of developing a complication to understand how this impacted payment. RESULTS We found a strong correlation between hospital complication rates and episode payments. For example, hospitals in the lowest quintile of complication rates had average total episode payments that were $1321 per patient less than hospitals in the highest quintile ($11,112 vs $12,433; P < 0.005). Cost savings was more prominent amongst high-risk patients where the difference of total episode payments per patient between lowest and highest quintile hospitals was $2160 ($12,960 vs $15,120; P < 0.005). In addition to total episode payment savings, hospitals with the lowest complication rates also had decreased costs for index hospitalization, readmissions, physician services, and postdischarge ancillary care compared with hospitals with the highest complication rates. CONCLUSIONS Medicare payments for bariatric surgery are significantly lower at hospitals with low complication rates. These findings suggest that efforts to improve bariatric surgical quality may ultimately help reduce costs. Additionally, these cost savings may be most prominent amongst the patients at the highest risk for complications.
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Affiliation(s)
- Andrew M Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Chen LM, Ryan AM, Shih T, Thumma JR, Dimick JB. Medicare's Acute Care Episode Demonstration: Effects of Bundled Payments on Costs and Quality of Surgical Care. Health Serv Res 2017; 53:632-648. [PMID: 28369885 DOI: 10.1111/1475-6773.12681] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate whether participation in Medicare's Acute Care Episode (ACE) Demonstration Program-an early, small, voluntary episode-based payment program-was associated with a change in expenditures or quality of care. DATA SOURCES/STUDY SETTING Medicare claims for patients who underwent cardiac or orthopedic surgery from 2007 to 2012 at ACE or control hospitals. STUDY DESIGN We used a difference-in-differences approach, matching on baseline and pre-enrollment volume, risk-adjusted Medicare payments, and clinical outcomes to identify controls. PRINCIPAL FINDINGS Participation in the ACE Demonstration was not significantly associated with 30-day Medicare payments (for orthopedic surgery: -$358 with 95 percent CI: -$894, +$178; for cardiac surgery: +$514 with 95 percent CI: -$1,517, +$2,545), or 30-day mortality (for orthopedic surgery: -0.10 with 95 percent CI: -0.50, 0.31; for cardiac surgery: -0.27 with 95 percent CI: -1.25, 0.72). Program participation was associated with a decrease in total 30-day post-acute care payments (for cardiac surgery: -$718; 95 percent CI: -$1,431, -$6; and for orthopedic surgery: -$591; 95 percent CI: $-$1,161, -$22). CONCLUSIONS Participation in Medicare's ACE Demonstration Program was not associated with a change in 30-day episode-based Medicare payments or 30-day mortality for cardiac or orthopedic surgery, but it was associated with lower total 30-day post-acute care payments.
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Affiliation(s)
- Lena M Chen
- Division of General Medicine, University of Michigan, North Campus Research Complex, Ann Arbor, MI.,VA Ann Arbor Healthcare System, Ann Arbor, MI.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Andrew M Ryan
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Terry Shih
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI.,Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jyothi R Thumma
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI.,Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Justin B Dimick
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.,Department of Surgery, University of Michigan, Ann Arbor, MI
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Ibrahim AM, Thumma JR, Dimick JB. Reoperation after Laparoscopic Gastric Band Surgery among Medicare Beneficiaries. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
IMPORTANCE Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures. OBJECTIVE To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional retrospective review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151,867 for non-critical access; cholecystectomy, 10,556 for critical access and 573,435 for non-critical access; colectomy, 10,198 for critical access and 577,680 for non-critical access; hernia repair, 4291 for critical access and 300,410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation. EXPOSURES Undergoing surgical procedures at critical access vs non-critical access hospitals. MAIN OUTCOMES AND MEASURES Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay >75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization. RESULTS Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P < .0001), diabetes (20.2% vs 21.7%, P < .001), obesity (6.5% vs 10.6%, P < .001), or multiple comorbid diseases (% of patients with ≥2 comorbidities; 60.4% vs 70.2%, P < .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.32-0.39; P < .001). Medicare expenditures adjusted for patient factors and procedure type were lower at critical access hospitals than non-critical access hospitals ($14,450 vs $15,845; difference, -$1395, P < .001). CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non-critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures, but were less medically complex.
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Affiliation(s)
- Andrew M Ibrahim
- The Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | | | - Jyothi R Thumma
- The Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B Dimick
- The Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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Scally CP, Shih T, Thumma JR, Dimick JB. Impact of a National Bariatric Surgery Center of Excellence Program on Medicare Expenditures. J Gastrointest Surg 2016; 20:708-14. [PMID: 26582598 DOI: 10.1007/s11605-015-3027-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/09/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION In 2006, the Centers for Medicare and Medicaid Services (CMS) issued a national coverage decision restricting bariatric surgery to designated centers of excellence (COE). Although prior studies show mixed results on complications and reoperations, no prior studies evaluated whether this policy reduced spending for bariatric surgery. We sought to determine whether the coverage restriction to COE-designated hospitals was associated with lower payments from CMS. METHODS We utilized national Medicare claims data to examine 30-day episode payments for patients who underwent bariatric surgery from 2003 to 2010 (n = 72,117 patients). We performed an interrupted time series analysis, adjusting for patient factors, preexisting temporal trends, and changes in procedure type, to determine whether the 2006 coverage decision was associated with lower Medicare payments above and beyond any existing secular trends. For these analyses, we included payments for the index hospitalization, readmissions, physician services, and post-discharge ancillary care. RESULTS After accounting for patient factors, preexisting temporal trends, and changes in procedure type, there were no statistically significant improvements in episode payments after (US$14,720) vs before (US$14,283) the coverage decision (+US$437, 95% CI, -US$10 to +US$883). In a direct assessment of payments for COE-designated hospitals (US$14,481) vs. non-COE-designated hospitals (US$14,756), no significant differences in episode payments were found (-US$275, 95% CI, -US$696 to +US$145). CONCLUSIONS We found no significant reductions in 30-day episode payments after vs before restricting coverage to COE-designated hospitals. Center of excellence status is not a proxy for savings to the healthcare system.
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Affiliation(s)
- Christopher P Scally
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes & Policy, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109, USA.
| | - Terry Shih
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes & Policy, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109, USA
| | - Jyothi R Thumma
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes & Policy, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109, USA
| | - Justin B Dimick
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes & Policy, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109, USA
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Affiliation(s)
- Tyler R. Grenda
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jason C. Pradarelli
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor2Surgical Innovation Editor, JAMA Surgery
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Scally C, Varban OA, Thumma JR, Birkmeyer JD, Dimick JB. Video Ratings of Surgical Skill and Late Outcomes after Bariatric Surgery. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Scally CP, Ryan AM, Thumma JR, Gauger PG, Dimick JB. Early impact of the 2011 ACGME duty hour regulations on surgical outcomes. Surgery 2015; 158:1453-61. [PMID: 26054323 DOI: 10.1016/j.surg.2015.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 04/20/2015] [Accepted: 05/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented additional restrictions on resident work hours. Although the impact of these restrictions on the education of surgical trainees has been examined, the effect on patient safety remains poorly understood. METHODS We used national Medicare Claims data for patients undergoing general (n = 1,223,815) and vascular (n = 475,262) surgery procedures in the 3 years preceding the duty hour changes (January, 2009-June, 2011) and the 18 months thereafter (July, 2011-December, 2012). Hospitals were stratified into quintiles by teaching intensity using a resident to bed ratio. We utilized a difference-in-differences analytic technique, using nonteaching hospitals as a control group, to compare risk-adjusted 30-day mortality, serious morbidity, readmission, and failure to rescue (FTR) rates before and after the duty hour changes. RESULTS After duty hour reform, no changes were seen in the measured outcomes when comparing teaching with nonteaching hospitals. Even when stratifying by teaching intensity, there were no differences. For example, at the highest intensity teaching hospitals (resident/bed ratio of ≥ 0.6), mortality rates before and after the duty hour changes were 4.2% and 4.0%, compared with 4.7% and 4.4% for nonteaching hospitals (relative risk [RR], 0.98; 95% CI, 0.89-1.07). Similarly, serious complication (RR, 1.02; 95% CI, 0.98-1.06), FTR (RR, 0.95; 95% CI, 0.87-1.04), and readmission (odds ratio, 1.00; 95% CI, 0.96-1.03) rates were unchanged. CONCLUSION In Medicare beneficiaries undergoing surgery at teaching hospitals, outcomes have not improved since the 2011 ACGME duty hour regulations.
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Affiliation(s)
- Christopher P Scally
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI; General Surgery Residency Program, Department of Surgery, University of Michigan, Ann Arbor, MI.
| | - Andrew M Ryan
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Paul G Gauger
- General Surgery Residency Program, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
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Varban OA, Reames BN, Finks JF, Thumma JR, Dimick JB. Hospital volume and outcomes for laparoscopic gastric bypass and adjustable gastric banding in the modern era. Surg Obes Relat Dis 2015; 11:343-9. [PMID: 25820080 PMCID: PMC4609545 DOI: 10.1016/j.soard.2014.09.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 09/21/2014] [Accepted: 09/23/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. As a result, it is possible that the influence of hospital volume on outcomes has attenuated over time. The objective of the present study was to examine whether the relationship between hospital volume and adverse events has persisted in the era of laparoscopic surgery. This study is based on analysis of State Inpatient Databases (SID) for 12 states from 2006 through 2011, which included 446,127 patients. METHODS Using hospital discharge data, changes in serious complications, reoperations and mortality over time, and the impact of hospital volume on outcomes among patients undergoing laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) were studied. Hospitals were stratified by operative volume, and using multivariable logistic regression to adjust for patient characteristics and procedure-type, the relationships between hospital volume and outcomes during 3 2-year periods were examined: 2006-2007, 2008-2009, and 2010-2011. RESULTS The rate of reoperations and mortality were low, and there were no significant differences between the highest (>125 cases/yr) and lowest (<50 cases/yr) volume hospitals for both LAGB and LRYGB. The volume-outcome relationship was most prominent when examining rates of adjusted odds ratios for serious complications at the lowest volume hospitals compared with the highest volume hospitals (LAGB: 1.65 [CI: 1.18, 2.30] for 2006-2007, 1.81 [CI: 1.36, 2.41] for 2008-2009, and 2.08 [CI:1.40, 3.09] for 2010-2011; LRYGB: 1.55 [CI:1.23, 1.95] for 2006-2007, 1.39 [CI:1.09, 1.76], and 1.39 [CI:1.07, 1.80] for 2010-2011). CONCLUSIONS Outcomes improved over the study period at both high- and low-volume volume hospitals. There remain significant differences in serious complications between the highest and lowest volume hospitals for both stapled and nonstapled procedures.
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Osborne NH, Nicholas LH, Ryan AM, Thumma JR, Dimick JB. Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. JAMA 2015; 313:496-504. [PMID: 25647205 PMCID: PMC4337802 DOI: 10.1001/jama.2015.25] [Citation(s) in RCA: 230] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides feedback to hospitals on risk-adjusted outcomes. It is not known if participation in the program improves outcomes and reduces costs relative to nonparticipating hospitals. OBJECTIVE To evaluate the association of enrollment and participation in the ACS NSQIP with outcomes and Medicare payments compared with control hospitals that did not participate in the program. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental study using national Medicare data (2003-2012) for a total of 1,226,479 patients undergoing general and vascular surgery at 263 hospitals participating in ACS NSQIP and 526 nonparticipating hospitals. A difference-in-differences analytic approach was used to evaluate whether participation in ACS NSQIP was associated with improved outcomes and reduced Medicare payments compared with nonparticipating hospitals that were otherwise similar. Control hospitals were selected using propensity score matching (2 control hospitals for each ACS NSQIP hospital). MAIN OUTCOMES AND MEASURES Thirty-day mortality, serious complications (eg, pneumonia, myocardial infarction, or acute renal failure and a length of stay >75th percentile), reoperation, and readmission within 30 days. Hospital costs were assessed using price-standardized Medicare payments during hospitalization and 30 days after discharge. RESULTS After accounting for patient factors and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes at 1, 2, or 3 years after (vs before) enrollment in ACS NSQIP. For example, in analyses comparing outcomes at 3 years after (vs before) enrollment, there were no statistically significant differences in risk-adjusted 30-day mortality (4.3% after enrollment vs 4.5% before enrollment; relative risk [RR], 0.96 [95% CI, 0.89 to 1.03]), serious complications (11.1% after enrollment vs 11.0% before enrollment; RR, 0.96 [95% CI, 0.91 to 1.00]), reoperations (0.49% after enrollment vs 0.45% before enrollment; RR, 0.97 [95% CI, 0.77 to 1.16]), or readmissions (13.3% after enrollment vs 12.8% before enrollment; RR, 0.99 [95% CI, 0.96 to 1.03]). There were also no differences at 3 years after (vs before) enrollment in mean total Medicare payments ($40 [95% CI, -$268 to $348]), or payments for the index admission (-$11 [95% CI, -$278 to $257]), hospital readmission ($245 [95% CI, -$231 to $721]), or outliers (-$86 [95% CI, -$1666 to $1495]). CONCLUSIONS AND RELEVANCE With time, hospitals had progressively better surgical outcomes but enrollment in a national quality reporting program was not associated with the improved outcomes or lower Medicare payments among surgical patients. Feedback on outcomes alone may not be sufficient to improve surgical outcomes.
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Affiliation(s)
- Nicholas H Osborne
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor2Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor
| | - Lauren H Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrew M Ryan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor4Department of Health Policy and Management, School of Public Health, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor4Department of Health Policy and Management, School of Public Health, University of Michigan, Ann Arbor
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Abstract
IMPORTANCE Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important. OBJECTIVE To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals. DESIGN, SETTING, AND PARTICIPANTS Observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. MAIN OUTCOMES AND MEASURES Number of inpatient medical consultations. RESULTS More than half of patients undergoing colectomy (91,684) or THR (339,319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%). Results stratified by complications were similar for THR. CONCLUSIONS AND RELEVANCE The use of medical consultations varied widely across hospitals, particularly for surgical patients without complications. Understanding the value of medical consultations will be important as hospitals prepare for bundled payments and strive to enhance efficiency.
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Affiliation(s)
- Lena M Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor2VA Ann Arbor Healthcare System, Ann Arbor, Michigan3Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor4Institute for Healthcare Policy
| | - Adam S Wilk
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor6VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Jyothi R Thumma
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor7Department of Surgery, University of Michigan, Ann Arbor
| | - Mousumi Banerjee
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor8Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
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Shih T, Scally C, Thumma JR, Dimick JB. Does Referral to Centers of Excellence Reduce Costs? An Evaluation of Medicare’s Center of Excellence Policy for Bariatric Surgery. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Scally C, Shih T, Thumma JR, Dimick JB. Evaluating the Financial Impact of Quality Improvement in Bariatric Surgery. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lok CE, Thumma JR, McCullough KP, Gillespie BW, Fluck RJ, Marshall MR, Kawanishi H, Robinson BM, Pisoni RL. Catheter-related infection and septicemia: impact of seasonality and modifiable practices from the DOPPS. Semin Dial 2013; 27:72-7. [PMID: 24400803 DOI: 10.1111/sdi.12141] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hemodialysis (HD) catheter-related infection (CRI) and septicemia contribute to adverse outcomes. The impact of seasonality and prophylactic dialysis practices during high-risk periods remain unexplored. This multicenter study analyzed DOPPS data from 12,122 HD patients (from 442 facilities) to determine the association between seasonally related climatic variables and CRI and septicemia. Climatic variables were determined by linkage to National Climatic Data Center of National Oceanic and Atmospheric Administration data. Catheter care protocols were examined to determine if they could mitigate infection risk during high-risk seasons. Survival models were used to estimate the adjusted hazard ratio (AHR) of septicemia by season and by facility catheter dressing protocol. The overall catheter-related septicemia rate was 0.47 per 1000 catheter days. It varied by season, with an AHR for summer of 1.46 (95% CI: 1.19-1.80) compared with winter. Septicemia was associated with temperature (AHR = 1.07; 95% CI: 1.02-1.13; p < 0.001). Dressing protocols using chlorhexidine (AHR of septicemia = 0.55; 95% CI: 0.39-0.78) were associated with fewest episodes of CRI or septicemia. Higher catheter-related septicemia in summer may be due to seasonal conditions (e.g., heat, perspiration) that facilitate bacterial growth and compromise protective measures. Extra vigilance and use of chlorhexidine-based dressing protocols may provide prophylaxis against CRI and septicemia.
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Affiliation(s)
- Charmaine E Lok
- Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
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Dimick JB, Nicholas LH, Ryan AM, Thumma JR, Birkmeyer JD. Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA 2013; 309:792-9. [PMID: 23443442 PMCID: PMC3785293 DOI: 10.1001/jama.2013.755] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations. OBJECTIVE To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. DESIGN, SETTING, AND PATIENTS Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n = 321,464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n = 6723 before and n = 15,854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n = 95,558 before and n = 155,117 after implementation of the policy). MAIN OUTCOME MEASURES Risk-adjusted rates of any complication, serious complications, and reoperation. RESULTS Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n = 179) vs hospitals without the COE designation (n = 519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]). CONCLUSIONS AND RELEVANCE Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.
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Affiliation(s)
- Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109, USA.
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Ramirez SPB, McCullough KP, Thumma JR, Nelson RG, Morgenstern H, Gillespie BW, Inaba M, Jacobson SH, Vanholder R, Pisoni RL, Port FK, Robinson BM. Hemoglobin A(1c) levels and mortality in the diabetic hemodialysis population: findings from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Diabetes Care 2012; 35:2527-32. [PMID: 22912431 PMCID: PMC3507600 DOI: 10.2337/dc12-0573] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Lowering hemoglobin A(1c) to <7% reduces the risk of microvascular complications of diabetes, but the importance of maintaining this target in diabetes patients with kidney failure is unclear. We evaluated the relationship between A(1c) levels and mortality in an international prospective cohort study of hemodialysis patients. RESEARCH DESIGN AND METHODS Included were 9,201 hemodialysis patients from 12 countries (Dialysis Outcomes and Practice Patterns Study 3 and 4, 2006-2010) with type 1 or type 2 diabetes and at least one A(1c) measurement during the first 8 months after study entry. Associations between A(1c) and mortality were assessed with Cox regression, adjusting for potential confounders. RESULTS The association between A(1c) and mortality was U-shaped. Compared with an A(1c) of 7-7.9%, the hazard ratios (95% CI) for A(1c) levels were 1.35 (1.09-1.67) for <5%, 1.18 (1.01-1.37) for 5-5.9%, 1.21 (1.05-1.41) for 6-6.9%, 1.16 (0.94-1.43) for 8-8.9%, and 1.38 (1.11-1.71) for ≥9.0%, after adjustment for age, sex, race, BMI, serum albumin, years of dialysis, serum creatinine, 12 comorbid conditions, insulin use, hemoglobin, LDL cholesterol, country, and study phase. Diabetes medications were prescribed for 35% of patients with A(1c) <6% and not prescribed for 29% of those with A(1c) ≥9%. CONCLUSIONS A(1c) levels strongly predicted mortality in hemodialysis patients with type 1 or type 2 diabetes. Mortality increased as A(1c) moved further from 7-7.9%; thus, target A(1c) in hemodialysis patients may encompass values higher than those recommended by current guidelines. Modifying glucose-lowering medicines for dialysis patients to target A(1c) levels within this range may be a modifiable practice to improve outcomes.
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